America: Slouching Towards Third World Status

“The best lack all conviction, while the worst
Are full of passionate intensity” — “The Second Coming”, William Butler Yeats

Yeats’ lines aptly describe our current age of political mediocrity. As we consider our politicians, we can hardly say that they’re our best. And the worst of them are full of passionate intensity, with passions driven by ideology, rather than fact-based analysis.

The United States has been in decline relative to other countries for the last 30 years. On key metrics, we’ve fallen behind our peer group of industrialized countries, such as the UK, France, Germany, and Japan.

Am I exaggerating? Well, according to the Corruption Perception Index, we rank 24th in the world (only slightly better than Qatar) for public sector corruption. We rank 25th (way behind our peer group) in the OECD for math scores among 15-year-olds.

Over the past 30 years, our national debt has grown from about 30 percent of GDP to over 100 percent, and will become much worse based on current trends. In a recent survey of 10,000 Harvard Business School Alumni, “66 percent of respondents see the U.S. falling behind emerging economies.” It is difficult to find many encouraging metrics.

If the above statistics don’t convince you, visit the New Delhi International Airport, then compare it with our JFK or Newark International Airports. In many areas, our infrastructure is an embarrassment, already inferior to that of many third world countries.

These facts (and many others) have escaped Romney, Santorum and our current group of Republican leaders. Obama and the Democrats aren’t doing significantly better at confronting these challenges.

In the 19th century, America aggressively compared itself against the world, and aspired to be “best in class.” We were an early adopter of kindergarten because we saw evidence that it would improve educational outcomes. In 1862, the U.S. was suffering through the Civil War, but Congress still had the foresight to pass the Land Grant Colleges Act, which created some of our finest universities. This investment was made because it was important for our country’s growth, and the U.S. clearly lagged behind Europe in college and university education.

It used to be, everyone was entitled to their own opinion, but not their own facts. But that’s not the case anymore. Facts matter not at all… What is important? What you want to be true, or what is true?… Truthiness is ‘What I say is right, and [nothing] anyone else says could possibly be true.’

Many Americans still have an almost cult-like belief that America is the greatest nation on earth. They systematically reject evidence suggesting we have significant room for improvement.

Sounds overly-dramatic? When opposing President Obama’s health care reform proposals, Speaker of the House John Boehner repeatedly proclaimed (with passionate intensity) that America has the “best health care system in the world.” Boehner is correct only if you exclude the entire developed world from the comparison. The U.S. ranks 50th for longevity and 49th for infant mortality, where we’re barely ahead of Belarus, Croatia and Lithuania.

I defy anyone to name a single important health care metric where the U.S. is considered a best-practice example as a nation. The only thing we lead the world in… is cost of health care. We have the world’s most expensive health care system. For example, our health care system costs almost twice Canada‘s, but we produce inferior results.

For Boehner to say we have the best health care system in the world, and not be laughed out of office, is at best ‘trained incapacity’ or ‘occupational psychosis.’

Boehner doesn’t have to support Obama’s health care reform plan. Obama’s reforms might make things worse. But, let’s have an actual debate grounded in facts, without inventing (and propagating) falsehoods about the current system.

China has been one of the most successful countries economically of the last 30 years. It’s fitting then to quote the architect of its economic renaissance Deng Xiaoping: “It doesn’t matter whether a cat is white or black, as long as it catches mice.” For too many Americans, what matters is not whether the policy works, but whether it fits our preconceived ideologies.

It’s the ultimate irony that we need to take the advice of a communist hardliner to put aside ideology, and focus on fact-based pragmatic solutions. Otherwise we’ll continue our slouch towards Third World status.

This post originally appeared at the Huffington Post and is posted with permission.

() The U.N. World Health Organization (the WHO) itself ranks the US #1 in care delivery that is important to patients. It issues another ranking at 37th because this quality of care costs more and is not delivered by government. The 37th rank is a political judgment that is not related to the quality of care delivered. That is the ranking that the liberal press always references.

Arguments against the quality of US health care are based on flawed infant mortality and life expectancy statistics, a confusion that the WHO promotes.

() Life expectancy at birth is a bad measure of healthcare quality, because it is exactly the countries with socialized healthcare who do not record premature births and births where the child dies within 24 hours. US hospitals record every birth having a single breath, including malformed and premature births, and the subsequent unavoidable deaths. Each time the US includes such a birth and death, it lowers our life expectancy statistic and raises our infant mortality statistic.

US infant mortality is as low as the best statistics in Europe when comparable cases are considered.

It is almost as if the relevant US government agencies want US healthcare to look bad. I haven't seen any statistics from those agencies that make an adjusted comparison.

() The US has much more accident and crime related death than Europe. This also lowers the life expectancy statistic, but has nothing to do with healthcare.

() For treatment of diseases, such as cancer, US citizens pay more and do better. This doesn't show ineffective healthcare. It shows that people are willing to pay to live longer, if they have the money and the option.

() When people cite the low costs of Medicare administration, they do not include activities that support Medicare but are not included in the spending figures. All governments have the incentive to under-report their healthcare costs. Despite Medicare's supposed efficiency, it suffers large losses to error and fraud, underpays for the care it proimises to deliver, and is so well planned that it is rapidly going broke. That is all within the government's control. They must like the situation.

() It is easy to spend less on healthcare and have great statistics: give the government a monopoly on paying for the care and for compiling the statistics. Cuba routinely issues infant mortality statistics that are lower than the US. I don't believe them.

() Healthcare Scandal in Britain
"The Patients Association in Britian reports hundreds of thousands in the past six years received nursing care that was often neglectful, demeaning, painful, and sometimes cruel.

Elderly people were left in pain, in soiled bed clothes, denied adequate food and drink, and suffered from repeatedly cancelled operations, missed diagnoses, and dismissive staff."

Bobito May 26, 2012 at 4:47 am

To paraphras one the arguments – We have lower life expectancy because we have higher rates of violent crime – that's no much of an argument for the US.

Higher deaths from auto accidents and crime are bad things. But, what does that have to do with healthcare comparisons? Those excessive deaths should be factored out when comparing health "systems" for treating disease, but they aren't factored out in the typically presented statistics. That is intellectually dishonest.

Arturo May 26, 2012 at 7:50 am

With all due respect Mr. Garland you seem to suffer from "trained incapacity" and/or “occupational psychosis.” as described in this article. No reasonably observant, unbiased person can honestly say there aren't massive problems with the US health care system, compared to our peers in the developed world.

With all due respect, you can call me names, but where are your facts?

The entire idea behind “occupational psychosis" is that your observations are colored by your ideology.

It should interest you that the commonly reported statistics are deeply flawed. If it doesn't bother you, maybe you are refusing to consider evidence. That refusal would go against your idea that you are an observant, unbiased person.

I would be happy to compare facts and learn about those much better health care systems. Enlighten me a little.

gzuckier May 30, 2012 at 9:53 pm

"With all due respect, you can call me names, but where are your facts?" seems a bit ironic, given the absolute lack of any facts supporting the touching faith that the US MUST have the best healthcare system in the world. You've been given some data here, and you've given us your opinion. Now how about you enlighten us a little.

Your reply below shows that you used the link I provided, and have read the facts I have relied on. My conclusion does not come from faith. If you want to discuss facts, then supply links and citations to what you rely on.

There are many measures of what might be the "best" healthcare system.

The simplistic statement that the US population spends much more and delivers less is flawed. The US spends more and delivers more in many areas. Possibly we could spend less and retain the quality of treatment delivered.

Any better policy should be grounded in measures which are understood in detail and not politically biased toward "more government is good".

gzuckier May 31, 2012 at 12:51 am

This is a nice collection of old shibboleths, some based on nothing but handwaving, some demonstrably false. I recognize the WSJ editorial page as the source for some.

" The U.N. World Health Organization (the WHO) itself ranks the US #1 in care delivery that is important to patients. It issues another ranking at 37th because this quality of care costs more and is not delivered by government. The 37th rank is a political judgment that is not related to the quality of care delivered. That is the ranking that the liberal press always references. "
The US ranked first in "responsiveness". While that is important to patients, it would seem that actual quality (i.e. ability to cure things) would also be important. The 37th ranking is not "political judgment", but, as stated in the report, isbased 50% on quality; another 25% on responsiveness (which we've already seen gives a big advantage to the US); and another 25% on how fairly costs are distributed (not on how high total costs are). Note that even if the US scored last on the financial term, since that is balanced by the first place in responsiveness, the quality term would have to be pretty bad to score 37th overall.

" it is exactly the countries with socialized healthcare who do not record premature births and births where the child dies within 24 hours. US hospitals record every birth having a single breath, including malformed and premature births, and the subsequent unavoidable deaths."
Actually, Canada uses the same birth statistics methodology as the US. But in any event, despite the belief of the WSJ oped writers that they can in 15 minutes come up with something that thousands of MDs have never been able to solve, there are in fact a couple of measures which count both stillbirths and postnatal deaths as a fraction of all late term pregnancies, for instance the Perinatal Mortality Ratio; and even using this measure, the US barely improves its ranking. Worse, other countries are improving, while we are not, so we are dropping our relative position.

"US infant mortality is as low as the best statistics in Europe when comparable cases are considered. "
Where was this study published? I'd love to see it.

"It is almost as if the relevant US government agencies want US healthcare to look bad. I haven't seen any statistics from those agencies that make an adjusted comparison"
Besides the WHO, other studies all come to the same conclusion.
Is US Health Really the Best in the World?
Barbara Starfield, MD, MPH
JAMA. 2000;284(4):483-485. doi:10.1001/jama.284.4.483
for one example. The CIA World Factbook for another, which lists US infant mortality rate at 49th from the best out of 122 countries.

As another piece of evidence; if the problem were mainly due to this problem with properly counting infant mortality, then the US would be at the top of the charts for life span after age 1; but in fact, the US scores 11th for life expectancy at 1 year for females, 12th for males, and 10th for life expectancy at 15 years for females, 12th for males. This is unlikely to be due to deaths that other countries count as miscarriages.

"The US has much more accident and crime related death than Europe. This also lowers the life expectancy statistic, but has nothing to do with healthcare."
Again, the hubris of a WSJ oped hack who assumes he can outthink public health professionals in their own field. (Same type of guy who solves the global warming question by deciding the climatologists undoubtedly forgot to include the sun in their models). From the above, "The data on years of potential life lost exclude external causes associated with deaths due to motor vehicle collisions and violence, and it is still the worst among the 13 countries."

I see that I was mistaken in my comment above. You do not seem to have read the information at the link I gave above. Support for my comment post is there.

The one reference you give is not a link. Sorry, I don't have a JAMA collection. If you know of a link, we could work with that.
–
You write: "As another piece of evidence; if the problem were mainly due to … properly counting infant mortality, then the US would be at the top of the charts for life span after age 1 ..".

You are confusing population mortality with infant mortality. The US population suffers much more death from auto accidents, crime, cancer, heart disease, and the obesity related diseases as compared to other countries. Looking at mortality after age 1 does not account for that difference, it only excludes differences in infant mortality.
–
I wrote: "The US has much more accident and crime related death than Europe. This also lowers the life expectancy statistic, but has nothing to do with healthcare."
You respond: "Again, the hubris of a WSJ oped hack"

I see that your style is to dismiss complicating factors. All such data is provided by hacks. I get some of my data from the British medical journal The Lancet and the CDC, as links through other posts.

The Lancet ranks the U.S. (first), then Canada, France, and Norway for cancer survival. The US has higher cancer rates, but better survival. This is despite the World Health Organization calling the French health system "the best in the world".

The British Health Service is skimping on maternity care, but reports great statistics. This puzzles me.

John Dewey was a social planner in education and a still celebrated founder of our modern public schools.

His ideas about the role of education do not fit a free and vibrant society, as incorporated in these quotes.

"Independent self-reliant people would be a counterproductive anachronism in the collective society of the future where people will be defined by their associations (1896)."

"The children who know how to think for themselves spoil the harmony of the collective society that is coming, where everyone would be interdependent (1899)."

spider May 26, 2012 at 1:28 pm

The 19th century – when we were rising so rapidly – was the age of robber barons, laissez-faire triumphant, gunboat diplomacy, and white supremacy. Inconvenient facts that the shmuck liberal author neglects to mention.

llisa2u2 May 26, 2012 at 4:18 pm

andrew- I suggest that you personally experience medical care and costs in New Zealand, England, Canada, Australia, and especially France. However, the cost of sun-screen is rather high priced in Nice, France these days.

Your comment to me is a bit subtle. Are you suggesting that I become ill in many countries? Is that a mean suggestion? I hope I have that wrong. That is a strange response to a policy discussion.

llisa2u2 May 26, 2012 at 8:55 pm

Andrew I did not mean that as a "mean" suggestion. (depending also on how you interpret the word "mean", all puns intended.) I am presuming that yes, you do have that wrong. Rather than just writing and mentioning conclusions from other writings that are not necessarily based on any factual statistics, nor factual experience, I am suggesting that it could clarify "reality" of comparisions of US medical care vs. other nations medical care if someone,perhaps "you" actually reported facts on some real valid level. The present policy discussion as you mention, is not really a policy discussion, but a rehash of specualtive reports.

llisa2u2 May 26, 2012 at 8:56 pm

"specualitive" is a mispelling, the correct word is speculative.

llisa2u2 May 26, 2012 at 9:48 pm

OH, and about the sunscreen remark; My daughter-in-law just returned from Nice two days ago. Sunscreen is outrageously expensive in the particular tourist on-the-beach-shop that she and her friends attempted to purchase some sunscreen. As Americans, they could not afford to pay that kind of price. However, medical care for French citizens and visitors is actually very reasonable. So the luxury item (actually sun screen lotion may not be a luxury item) is not affordable but the essential medical care is affordable. I contend that really, it's pretty much the exact opposite here in the US. And, I was just having some fun with my comment, and not really trying to make it into an intense debate really. But, I sure will get into some intense commentary on my own site, maybe as soon as June 2012, I hope! And one topic I'm pretty interested in, is the subject of US medical care, costs, and standards as compared to other nations medical care. Because I have actual documented information from friends that have experienced medical care and costs from those countries, that I mentioned, I know that the US medical care is not better than those other countries, and may in fact be a lot worse. So, I am writing that WHO is not the one that is reporting "WE spend more and get less", but actual human beings that are citizens from other nations are reporting and can confirm, by comparing billings for treatments that "they have better medical care options and pay less for better quality medical care in a number of advanced nations compared to US citizens for similar medical care in the US." I can personally report from my own personal experience some real "snafus", and that's a "nice" way of suggesting and continuing my "strange" response to a discussion that I don't think is really a policy discussion at all. BTW- Dewey's writings are pretty good and pretty relevant. What's the source of the 2 Dewey quotes?

The Dewey quotes are at the link I supplied under the first words John Dewey. A Google search gives other support for them. I find those quotes appalling.

No one can be everywhere or understand the world only by individual experiences. Statistics have a place, and individual experience and skepticism has to be used to question statistics.

You have me wrong when you wrote "Rather than just writing and mentioning conclusions from other writings that are not necessarily based on any factual statistics". I link to my sources and the criticisms that seem valid for interpreting those sources.

How do you form your opinions on public policy? I think statistics must come into it.

The WHO statistic that the US is 37th in health care efficacy is commonly repeated and is deeply misleading. Support for this is at the link I gave above (USA Healthcare is First – Infant Mortality is Low). The WHO offers various rankings, and this is merely the most political one, showing the worst result for the US. The WHO rankings are untrustworthy when you look under the surface at their methods, also at the link.

About cheap-but-good French healthcare. The current cost of care to particular individuals is not the whole story. I am skeptical of what governments report about costs. There is always a strong incentive to report low costs and account for much of the cost in unaccounted categories on the side.

I have seen lots of information about the failures in British healthcare. Possibly the French do it better, and you can supply your sources.

I note that France is currently going broke, considering the Euro crisis. Is the French government doing better managing health care finances than it is doing with its national finances? If so, is there an analysis which reports in particular what the French are doing better and why they are cheaper than US healthcare?

To llisa2u2,
You value individual stories. By coincidence, I happened upon this video which criticizes Canadian health care. The main point is that Canada saves money by making patients wait, and sometimes die before they can be treated.

Sally C. Pipes understands and lived under Canada's national health care system. She gives some personal stories and other facts.

gzuckier May 31, 2012 at 1:44 am

Those personality theorists divide people up into those who decide on the basis of analyzing data, and those who make decisions based on their gut and/or what they have been told by individuals considered to be reliable and authoritative. Furthermore people tend to be divided up pretty much bipolarly on this measure without a lot of people inhabiting the middle, partly one and partly the other; and these two types of people do not trust each other's decisions or decision making. This is the true dividing line in America today.

On the one hand, you have people brandishing studies saying that US healthcare is not the best in the world; that civilian deaths in Iraq were in the hundreds of thousands; that fossil fuels look responsible for global warming; that cigarettes cause cancer; even that species derive from evolution.

On the other hand are those who follow opinion leaders who assure them that there are serious doubts about all of the above, even though a coherent package of data which would overturn the opposing conclusions is not presented; because that data is neither required, nor would it be sufficient. And not just the data supporting the opposing position, but the whole process of analytical thinking itself, is disdained as easily subverted (lying with statistics; the numbers way whatever you want them to say; you can make the models say anything you want, etc.). And of course, the folks usually thought of as the faith-based community, the followers of organized religions, are natural members of this community. Inherent in this is, naturally, the assumption that those who oppose the thoughts, opinions, and beliefs of the trusted authority must be, therefore, at worst deliberately lying for some evil end, at best gullible followers of these lies; they can't be just good people who have misread the data, because that behavior is totally alien to the hierarchical/authoritative/gut-driven community.

Although it is hard to overcome that natural tendency to see one's own thinking process as superior to the other, it would be reasonable to assume that neither system really has a superior advantage, but that any advantage would be situation-dependent. Both types of thinking can lead to correct or to incorrect conclusions. Data-driven people are paralyzed when there is insufficient data and become ineffectual. But it seems inescapable that in the current political environment, the hierarchical/authoritative/gut level folks have been corrupted by what I can only characterize as an influx of corrupt and/or just wrong leaders. There were no WMD in Iraq, and we did not create a model democracy there for the Arab world to emulate. Scientists are not generally forging results to bring in enormously lucrative grant money. The US is not being bankrupted by welfare queens. etc. etc. This set of opinion leaders has allied itself firmly with the few (far less than 1%) who represent the American plutocracy (or was bought off by them in the Reagan years) and thus every acceptable opinion is, quite predictably, that which most serves the needs of this wealthy minority, no matter how much it may injure the vast majority of American citizens.

It seems that we are living through the Enlightenment in reverse; rather than the new evidence-based reasoning rolling back the old faith-based power structure, we now see an organized faith-based attempt to delegitimize individual decision making and inquiry, and higher education in general. Ironically, the hierarchical authoritarian followers are the first to insist that they are the individualists; this opinion, like most of the ideas they repeat, can be seen copied verbatim on countless websites reprinting word for word the latest talking points from the Wall Street Journal editorial page or whatever other opinion leader has the latest word.

And thus it is with healthcare. Every study points to the US having not the best healthcare system in the world; not even midpack for the advanced first world nations; but one of the worst in the industrialized world; just in overall quality of care, before any considerations of finances or fairness are considered. Those who disagree have no real data to support their assertions of American superiority, and are left with the position that the default hypothesis would have to be that America is superior, and quibbling and individual measures in individual studies. But, as with everything in science, when all the studies point more or less in the same direction, even do individual items may be flawed, the conclusion is usually pretty clear.

So, the data-driven folks present study after study, in the firm expectation that, if only enough data can be amassed, "the other side" will be convinced by them, as well. But of course, as we see in these comments, all the data in the world will not change the minds of people who follow those who hold an opposing belief, not until their thought leaders change their public positions.

And, in a mirror image, the believers in America's divinely guaranteed natural superiority in everything assume that their opponents can be dissuaded from their evil beliefs by haranguing, insulting the motives, ethics, and personalities of those who they see as the evil "opinion leaders", and generally doing everything except provide a solid model of data that would bolster their case, since that would never work on them. And they too are doomed to fail.

The problem here is that, while many still believe that America is the best nation, they lack the motivation and determination to ensure to keep it that way. To make matters worse, this mentality seems to be spreading. I can only hope something is done to correct this soon.